Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Friday, December 30, 2005

I thought I had a McGuffin when I saw this in a presentation at the Norheast Epidemiology Conference. At a Creation Science Fair in Texas, First Prize went to Eileen Hyde and Lynda Morgan (grades 10 & 11) who "did a project showing how the power of prayer can unlock the latent genes in bacteria, allowing them to microevolve antibiotic resistance. Escherichia coli bacteria cultured in agar filled petri dishes were subjected to the antibiotics tetracycline and chlorotetracycline. The bacteria cultures were divided into two groups, one group (A) received prayer while the other (B) didn't. The prayer was as follows: "Dear Lord, please allow the bacteria in Group A to unlock the antibiotic-resistant genes that You saw fit to give them at the time of Creation. Amen." The process was repeated for five generations, with the prayer being given at the start of each generation. In the end, Group A was significantly more resistant than Group B to both antibiotics."

Alas (or perhaps fortunately), this turns out to be a parody, which took in a lot of people. (Yes, we have a crack team of fact checkers.) However, there are real Creation Science Fairs, although it turns out the students seldom do anything that resembles an experiment, they just ramble on about how the Bible explains everything. The same turns out to be true of grownup "Creation Scientists". (I particularly recommend the essay entitled, "In the Early Earth, Were All the Months Exactly Thirty Days Long?")

The occasion for inflicting all this dreck on you is the astonishing case of Hwang Woo-suk. Now that it turns out his entire portfolio of biotechnological breakthroughs was fraudulent, and that the South Korean government's $65 million investment in his work was simply stolen, many people, particularly of the ilk linked above, are triumphantly claiming that the fundamental credibility of orthodox (as it were) science has been exploded.

The precise opposite is true, of course. Creation science cannot possibly be falsified, because it begins with the conclusion and reasons backward from there. If someone has the temerity to question some part of the chain of reasoning, creationists just introduce more epicycles. Real science, however, is credible precisely because it is falsifiable. If Hwang worked for the Institute for Creation Science, his pursuits obviously would have been different, but whatever they were, it would be impossible to discredit him.

And in this connection, I highly recommend the comments to my previous post.

Thursday, December 29, 2005

In response to my recent posting about the impact of the Internet so far, and its likely future, a commenter directed us to Cas Sunstein's essay on the subject. Sunstein is concerned that the Internet allows people to completely control the information and ideas they are exposed to, and that the day may come when there is no longer a marketplace of ideas, but an archipelago of ideological and informational islands, scarcely in communication with each other.

Of course, it's really only a matter of degree. Even in the realm of dead trees information, people tend to favor books and magazines that reinforce, rather than challenge, their current beliefs, while the corporate media filter and spin information into a generic pudding of empty intellectual calories, guaranteed not to give anyone the get up and go to get off of their island and see what the folks are thinking across the channel.

It's a real problem. How can we talk with people who we might want to persuade, and how can we make sure we listen to people who might want to persuade us of something? I can go on all I want here about evolution and single payer national health care, but it's unlikely there will be many creationists or free market fundamentalists among my readers.

Dr. Darshak Sanghavi, in the Boston Globe Magazine a couple of weeks ago, showed that he is aware of this problem. The cover teased his story as "Vaccines and Autism? Weighing the benefits of shots against the risks." His story is titled "The Secret Truth," and it starts off by sympathetically profiling people who are convinced that vaccinations made their children autistic. "Uh oh," I'm thinking, as I start to read, but Sanghavi ends up firmly grounded in the reality based community. He reviews the overwhelming evidence that vaccination, and thimerosal, are unrelated to autism, gives RFK Junior the thorough thwacking he richly deserves, and makes it clear that vaccination has been an immense, and indisputable benefit to humanity. His secret truth is that since most kids in the U.S. get their shots, children whose parents refuse are unlikely to be exposed to measles, mumps, rubella, etc. and so they will probably get away with it. Under the circumstances, accepting immunization for your kids is socially responsible, but offers little individual benefit.

So he's set a little honey trap for people looking for reinforcement of their prejudices against vaccination. (And he's been completely honest, even when it might hurt his cause of having every child get the full course of immunizations.) In the marketplace of ideas, it appears that truth is prevailing in this particular case. (Although RFK Jr. still appears to be welcome in respectable society, is still publishing in large circulation magazines and appearing on television.)

But in many other important instances, the marketplace is not functioning. How is it that a majority of Americans still do not believe in evolution? It is because they get their information from their preachers, and liars on television, and delusional writers. They don't read Stephen J. Gould or Richard Dawkins. Many people believed that the Internet would expand and enhance the marketplace of ideas, but I now share Sunstein's fears. Once those folks begin to use the Internet as their portal to information, the chances that they will encounter challenges to their beliefs go down. The newspaper and television at least pretend to a bogus "balance" -- they treat creationists respectfully, report on their activities and quote them, but not without giving equal time to people who actually know something and are capable of rational thought.

I feel that it is very important that we think hard about how to use the Internet to promote dialogue and debate, to reach across ideological divides, and to create ground on which ideas have to fight for their lives and honor. I've tried a couple of experiments in that direction, without much success. Does anyone have any ideas?

Wednesday, December 28, 2005

I've been "tagged" with one of those "memes" by Revere, and I suppose I ought to be a good sport.

4 jobs I've had: I mentioned managing the concession at the town beach once before, and I also mentioned being a community organizer in Philadelphia. I once had a job on an assembly line packing boxes of boxes into boxes. After I'd been staring at the conveyor belt for hours, when they turned it off for maintenance, I would see it quite clearly and convincingly moving backwards. Is this a well-known illusion? Finally, I will now reveal that I was once a member of the resident acting company at a theater in Pennsylvania.

4 movies I could watch over and over: Probably none, I'm not really a repeat consumer of movies. But I definitely liked One Flew Over the Cuckoo's Nest, Olivier's Henry V, Ran, and since this game seems to call for confession, The Blues Brothers (in which I perceived a tender pathos).

4 TV shows I love to watch: I don't have cable. The only shows I care about are Red Sox and Patriots games. Sometimes I watch Jeopardy. I generally avoid TV news.

4 places I've been on vacation: I don't really do a lot of vacation travel either, though I've traveled a lot on business. I did go to the Spoleto festival in Charleston one year, thanks to a friend, and I have talked about my trip to San Quintin in Baja California Norte, and I used to go to Santa Barbara every year where my ex's father lived, and one year we went to San Francisco. I toured England and Wales with my grandparents as a pimply pubescent. On business, I've been to Little Rock, Puerto Rico (stayed in Isla Verde), Seattle (went to Mt. Ranier), Houston, Chicago, Detroit, St. Louis, Miami, Baltimore and DC many times, Portland Maine . . . I could go on and on, I've been all over the U.S.

4 web sites I visit daily: Check the side bar for some good ones. I'm gonna plug Today in Iraq, Buzzflash, and this one is weekly but that's how often they update, the British Medical Journal. And of course, Effect Measure.

Tuesday, December 27, 2005

While our Christian neighbors prepare to leave the rest of us to pestilence, famine, war and damnation as they are raptured up to the Heavenly City, some of our more scientifically-oriented compatriots expect to pass on to techno-heaven in the coming singularity. The Transhuman movement, which is well represented here, envisions the coming of the Posthuman, an entity based somehow on human consciousness but transcending the well-lamented limitations of the flesh -- you know, those annoying little problems such as mortality, suffering, limited knowledge and intellect, inability to be instantaneously in Ouagadougou after breakfast on Mars, or to be in both places at once.

They expect this to be achieved step by step. First, current technologies will continue to advance so as to extend life span, retard aging, tighten the interface between human and computer, etc. Then we will understand aging and degenerative disease at the molecular level and achieve perfect health and practical immortality. On about the same schedule we'll start wiring computers directly to our brains and we won't even have to use Google any more, we'll just know everything. Maybe we'll also want to do some body modification and grow wings or the ability to leap tall buildings in a single bound, whatever you like. Oh yeah, long lasting erections on demand, speed reading for everyone, absolute pitch, whatever. Then we'll develop a complete map of every neural connection and the processing rules that generate individual human consciousness and self-identity, and learn how to upload it to computers so that we can abandon the despised fleshly mode entirely.

Some people think these visions, on the whole, are simply improbable and belong in the realm of science fiction. Others object to even some of the plausible proposals for human enhancement technologies on ethical grounds. These objections come from conservative religious viewpoints, including the folks who are counting on the Big Guy in the Sky to rapture them on up to the higher state; from environmentalist viewpoints (such as Bill McKibben); and from various other directions.

Some condemn specific technologies which offer prospects for human enhancement, such as embryonic stem cell research, on specific grounds. But a broad theme of objection has to do with a concept of sanctified "human nature." Enhanced humans won't actually behuman any more, say the critics, so instead of benefitting humanity, transhumanism proposes to destroy it.

This can be seen as a humanist objection, but then it would seem to be in conflict with the prevailing attitude of liberal humanists that the achievement of human potential is the highest value, in other words human nature is what we make of it, and we should aspire to the best. The fulcrum of debate would then be finding the point at which human potential has been fully achieved, beyond which the thing is no longer one of us.

I'm not sure there can be an answer to that. On a very mundane level, we're having trouble deciding what constitutes amelioration of disability or disease, and what constitutes enhancement. For example, there is the question of giving growth hormone to children who are merely short. Is that enhancement, or treatment?

But there is one issue that I am personally fairly clear about. Transhumanist ideology is profoundly individualistic. The technologies they champion require a huge capital investment to pursue, and will inevitably be extremely expensive should they become available. Yet they do nothing to respond to the pressing problems of the majority of humans, right now, today, who do not enjoy even a basic standard of housing, nutrition, education, medical care or safety. Transhumanist discourse is about directing vast resources to pursuing a fantasy of an exclusive utopia for a tiny elite. The fate of the obsolete, merely human masses is of no consequence to them. That is neither liberal, nor humanist.

Monday, December 26, 2005

Just to get started again, there's this little question of war. Last night after the standard ritual engorgement, frivolity, and subtextual familial tension, I checked out the Bears vs. Packers (hey C., there are worse vices), on Fox. During the third quarter one of the announcers said words to the effect that we're all thinking about the troops in Afghanistan and Iraq, wishing them God speed, stay safe, and come home soon -- remarks I'm sure we all endorse.

Then the other guy chimed in: and thanks to the troops for their courage and bravery "preserving our freedom to celebrate Christmas, as each and every one of us did this morning." This statement was so inane and so offensive, on so many levels, that I can't scarcely decide what I want to say about it. The idea that Americans would not have the freedom to celebrate Christmas if U.S. troops weren't in Afghanistan and Iraq having their parts blown off and blowing up the local folks is so transparently preposterous that you wouldn't accept it as parody, but this clown was obviously completely serious.

Wierd as it may be, it's of a piece with the Resident's assertion that the war is necessary to prevent al Qaeda from establishing a new Caliphate from Indonesia to Spain. You would think that prospect would alarm the Spaniards more than it does Mr. Bush, but they seem strangely unconcerned. We actually have a political and media culture in which these demented fantasies are treated as serious discourse.

Yet beneath the first layer, of plain old nonsense, is the even more disturbing text that the war is in defense of Christianity. How did the dominant version of Christianity in the United States come to be one which radically and forcefully rejects the teachings imputed to Jesus in the gospels? Why does this religion of hatred, bloody vengeance, and domination even merit the name of Christianity?

As I was driving home this morning I picked up a program of old time New Orleans jazz on the radio. They played an old, scratchy version of Down by the Riverside. I've always known the lyrics as beginning, "Gonna lay down my burden, down by the riverside," and then of course the chorus is "Ain't gonna study war no more." I had wondered about the locution of studying war -- why not "Ain't gonna go to war no more," or "Ain't gonna have no wars nor more"? What's with the "studying"?

But this version went, "Down by the riverside, gonna lay my Bible down, gonna lay my Bible down . . ." and then, of course, it made perfect sense. These were probably the original words, and they have been changed to avoid giving offense. (Can any folklorists out there confirm that?) The predominant theme of the Old Testament is war. God exhorts the Hebrews to slaughter, rape and enslave other peoples -- including completely innocent people who have done them no harm, whose land God wishes for them to seize. At other times, God brings war and enslavement to the Hebrews. To study the Bible is to study war. And it is that God who revels and glories in slaughter who is the American Christian God.

Saturday, December 24, 2005

I know this may seem appalling and even improbable, but I will be disconnected from the AllThing for a couple of days. You probably won't hear from me until Monday afternoon. It will be interesting to see what effect this has on my D2 receptors.

So let me take this opportunity to thank everyone who has contributed here over the past year. C. Corax for all the great comments and lots of tips, also Dr. Y and M.A.R. for good tips, Dread Pirate Roberts and Rexroth's Daughter who were among the first regulars here (and who maintain a very interesting blog), along with Speechless and JaneBoatler (hope you're okay JB and back at home!), Whisker and Matt and FF and everyone at Today In Iraq for the tremendous public service they do (and I don't know how they even find the time to visit here), TheaLogie, NeoLotus, JGarrow, Gaudeamus, Philalethes of course (who is an elegant writer indeed and do check him out) and everyone who has contributed with great comments (and I apologize because when you do this, you always end up leaving someone out, I know I'm going to slap my forehead as soon as I finish this post). Thanks to Revere for covering for me and raising the standard here.

Thanks to Blake, and sorry for the tease, but Blake and I will be launching a new project soon that I hope will interest y'all. We aren't quite ready to announce it, but to show a little more leg, as I have said many times I want to bring more physicians into the kinds of discussions we have here. Blake is an M.D. and we're setting up a vehicle to focus in a more sustained way on medicine and the health-care non-system in the U.S.

But don't worry, Stayin' Alive isn't going away. I'm hoping we can make it bigger and better.

BTW: The story about the Little Red Book turns out to be a hoax. While that is a relief, I suppose, the bad news is that it was so believable.

Friday, December 23, 2005

This is pretty much of a thumbsucker but I've been thinking about it lately and I'm feeling lazy today so this is what you get.

After the avalanche of visionary claptrap that fueled the stock bubble of the late '90s washed away along with Pets dot com, we stopped hearing a whole lot about how the Internet was going to radically transform society. Typically, back in 1999, it was going to create some version of a libertarian paradise, along with a whole new economic order out of an orgy of destruction.

Well, retail stores are still around and you still can't get a parking space at the mall today on Dec. 23. Our political trajectory has been in the opposite direction from libertarianism, the mass media are dominated by fewer and huger corporations than in 1995, and we're still driving to the office every morning. On the other hand it's definitely hurt the bricks and mortar purveyors of porno, made it easier for students to research their term papers (or cheat on them), and it's made librarians lonely.

As for social movements, it seems particularly useful to the illegal and reprehensible, from violent jihadis to white supremacists to pedophiles. Obviously more conventional political activists also use it but it has yet to fundamentally change political processes or the poltical order.

But give it time. The Internet is starting to undermine the power of the corporate media to selectively frame issues and filter truth. Although that power did not emerge in time to save us from the national disaster of the past five years, it is becoming more evident lately. By creating communities without regard to geography, and putting much of the cultural heritage and accumulated knowledge of humanity at the immediate disposal of anyone with moderate means, it is already changing the production of knowledge and ideas. Of course, when we communicate over the Internet instead of meeting in a conference room or a living room, it's easy for the government to spy on us, if that should be an issue.

It's certainly having an impact on health care, though only around the edges. Radiologists in Australia and India read the CT scans done in New York and Milwaukee. Doctors can get instant access to medical research and drug information. They can even enter your symptoms into Google, believe it or not, and have a diagnosis in seconds. Communicating with patients by e-mail is the hot new thing.

It's impact on public health knowledge and practice is less evident.

Where do you think it's taking us? How will it change our lives and institutions in the next ten years? Anybody have a crystal ball? What has it meant to you?

Thursday, December 22, 2005

In the new JAMA (argghhh, subscription only) there's a summary by Bridget Kuehn of recent research that finds that when exposed to cocaine, lower status monkeys are more susceptible to addiction than the alpha monkeys who get all the best bananas and monkettes. These experimenters relate this finding to the number of a specific kind of dopamine receptor in the animals' brains, of which the boss monkeys have more. Both classes of monkeys lose D2 receptors while they are actively using, but the high status monkeys grow them back faster and are also less likely to relapse. Assuming this is also true of humans (and we can't do the experiment), their proposed solution is a drug that makes you grow D2 receptors.

Now, while it is true that we can't do the experiment, there has already been plenty of sociological research which shows that middle class and above type people are just as likely, if not more likely, than people from less privileged backgrounds to try illicit drugs. But it's the people who don't have good jobs to go to on Monday morning or futures worth preparing for who are more likely to end up addicted. (And please don't even ask me about the scene at my old college. I know plenty of people who were flying through the ozone every weekend, who are now pouring martinis on the roof deck on Martha's Vineyard every July.) I don't know if that has anything to do with D2 receptors and frankly, I don't care, because the first solution I think of for that problem is not yet another pill. It's creating opportunity for more people, which I consider superior to creating a new model of oppressed drudge with extra D2 receptors.

Then we come to new research by Thompson, Tangen, Goodman, and etc. etc., which finds in a prospective cohort study (very strong design) that men without diagnosed cardiovascular disease at baseline, who have or develop erectile dysfunction, are at much higher risk for heart attacks, strokes etc. than men who continue to lift the bale, as it were. The reasons are undoubtedly that not being able to get it up is a symptom of conditions that are risk factors for CVD -- smoking, obesity, lack of fitness, circulatory impairment, and so forth. But we all know what a guy is supposed to do nowadays if Private Partz won't snap to attention -- ask the doctor for the little blue pill. Maybe it would be an even better idea to figure out exactly why the soldier is AWOL and fix the problem -- then you wouldn't die of a heart attack.

Pretty soon, they'll come up with a pill for not liking your boss, another one for hating all the TV shows that are on, a pill for people who don't take their pills, and the major breakthrough, a pill to cure being mad at the government.

I know that I'm not alone in feeling a bit conflicted over how to talk about that majority of Americans who tell pollsters they do not believe in the theory of evolution and think God made the whole ecosphere. It is not the case that something about human nature makes it impossible to cure the majority: among countries with universal literacy, the U.S. suffers uniquely from this endemic dementia.

But we're afraid that if we stand up in public and say that the promoters of creationism and intelligent design are either charlatans, who don't really believe what they say but are running a scam to separate the ignorant and pathetic from their pittances; or are themselves fools and fabulists, we're just insulting the people we want to convince, and that probably won't get us a respectful hearing. On the other hand, if we appear to take these beliefs seriously, and engage them respectfully, we give them undeserved dignity.

Judge John E. Jones III has done a major public service. With the full majesty of the court, he treats creationists as buffoons. His opinion in the Dover schoolboard case creates an opening through which we must advance. Denying that the ecosphere in which we live developed over billions of years through evolution is outside the realm of sane, socially respectable opinion. It disqualifies people from public office because it shows them to be intellectually crippled, incapable of distinguishing truth from falsehood. People who espouse it are to be pitied and offered counseling, like people who think that extraterrestrials are controlling their brains by radio waves. This is not a controversy, okay folks? The earth is round, it goes around the sun, it is billions of years old, life here evolved through genetic mutation, recombination, and natural selection. If you don't believe that, what you are is ignorant, deceived, used, and wrong. This is not a war of ideas, it is a simple choice between knowledge and ignorance.

And that is what people running for political office, including president of the United States, need to say. In public. Even without being asked. Otherwise, they won't get my vote.

Wednesday, December 21, 2005

It seems a doctor in has gotten into some trouble with the authorities for injecting cancer patients with insecticide, specifically dinitrophenol (it seems the AP story misspelled the name of the compound) which is toxic to the nervous system, liver and kidneys. (Not to mention, it's a high explosive!)

Unfortunately, the stuff the doctors legally inject cancer patients with isn't a whole lot better. You can check out the side effects of all the stuff here. Examples:

Cyclophosphamide (Cytoxan; CTX): may be administered orally or intravenously. Side effects include bone marrow suppression, hemorrhagic cystitis (severe inflammation of the bladder with blood in the urine), hair loss, electrolyte imbalances (especially sodium), gastrointestinal toxicity as manifested by nausea and vomiting and possible liver dysfunction. A rare lung toxicity manifested by lung inflammation and similar to "Busulfan lung" has been seen. Sexually, testicular atrophy, loss of periods (menses) and ovarian failure can occur.Cis-platinum (Platinol): administered intravenously. The patient should be well hydrated prior to administration of the drug. It has been shown that administration in the face of poor hydration increases the likelihood of developing side effects. In patients with kidney dysfunction, impaired hearing, preexisting peripheral nerve damage (neuropathy) or past history of allergies to platinum this medication should be given (if at all) with extreme caution. Side effects include nausea and vomiting, anaphylactic reactions (consisting of fast heart rate, wheezing, lowered blood pressure and facial edema), kidney damage (nephrotoxicity), decreased hearing (ototoxicity), nerve damage (neurotoxicity; peripheral neuropathy) manifested by tingling and numbness of the hands and/or feet, bone marrow suppression with increased risk of bleeding and infection, electrolyte (sodium, potassium and magnesium) disturbances and possible heart toxicity (manifested by EKG changes) may be seen. It is important to discuss these issues with your physican so htat you may inform him/her of any symptoms, which may be attributable to the use of this drug.

And so on and so forth. They're all about equally appalling. Of course, the difference here is that all of these drugs have been FDA approved, meaning that in addition to being highly poisonous, they've been shown in some cases to result in shrinkage of tumors visible in X-rays, or to give people on average a few weeks or months of additional life, which as far as I know is not the case for dinitrophenol. On the other hand, an injection of dinitrophenol does not cost tens of thousands of dollars.

Cancer chemotherapeutic agents almost universally have very severe side effects, don't cure cancer, and buy at best only limited added survival. However, they are extremely expensive and they do buy yachts and cadillacs for drug company investors and oncologists. Not that some of these agents aren't worth trying in the right circumstances, but all the advances we have made in understanding the biological basis of cancer have yet to translate into major therapeutic benefits, contrary to anything you may have heard or read.

It's just the same old story -- we spend tens or hundreds of thousands of dollars to try to rescue seriously ill people, with limited benefit at best. We don't spend four bucks to save a poor kid from malaria, malnutrition, or fatal diarrhea.

Dec. 20, 2005 — - President Bush's National Security Adviser Stephen Hadley today labeled Iran "probably the No. 1 supporter of terror in the world today" and claimed a growing consensus between the Bush administration and its critics on the way forward in Iraq.

Speaking at the Center for Strategic and International Studies in Washington, Hadley said Iraq's recent parliamentary election is one way to offset Iran's influence in the region, claiming the high turnout on Sunday could help trigger democracy throughout the region.

"That is why it is so important that the terrorists be defeated in Iraq, and that Iraq be a showcase, in some sense, of a competition between the ideology of the terrorists and the ideology of freedom and democracy," Hadley said.

Hadley said he hopes that ideological struggle will spread to Iran. "One of the questions we keep asking is, when are the Iranian people going to begin to ask themselves, 'If Iraqis in Iran can participate in a free election in Iraq, why not us?'"

Hadley apparently doesn't know who won the election in Iraq -- Shiite religious parties, closely allied with Iran's ruling clerics. Many of their leaders, in fact, were living in Iran until the U.S. brought about regime change. The Iranian government praised the elections in Iraq and welcomed the results. Iraq's central government will be very weak, barely more than symbolic, but the majority of the country's population, oil resources, and military, will end up under the control of the Ayatollahs. (And by the way, Hadley is also apparently unaware that the Iranian government was elected.)

Democracy depends on a democratic political culture, not the ritual of voting. Iraqis have elected a fundamentalist, clergy-dominated government hostile to Israel, hostile to the United States, and closely tied to Iran. Now the plan is to keep U.S. troops in Iraq in order to protect and defend this government, build up its armed forces, and help it defeat the Sunni Arabs and secularists who do not wish to live in a Shiite theocracy. Mr. Hadley, and the Resident, define that proposed outcome as "victory."

Are they nuts?

(Note: Public health is about everything -- well, everything in the human realm, anyway -- so I get to talk about anything I want to. So there.)

Tuesday, December 20, 2005

Researchers Find Barbie Is Often Mutilated LONDON, Dec. 19, 2005 (AP) Barbie, beware. The iconic plastic doll is often mutilated at the hands of young girls, according to research published Monday by British academics.

"The girls we spoke to see Barbie torture as a legitimate play activity, and see the torture as a 'cool' activity," said Agnes Nairn, one of the University of Bath researchers. "The types of mutilation are varied and creative, and range from removing the hair to decapitation, burning, breaking and even microwaving."

Researchers from the university's marketing and psychology departments questioned 100 children about their attitudes to a range of products as part of a study on branding. They found Barbie provoked the strongest reaction, with youngsters reporting "rejection, hatred and violence," Nairn said.

"The meaning of 'Barbie' went beyond an expressed antipathy; actual physical violence and torture towards the doll was repeatedly reported, quite gleefully, across age, school and gender," she said. . . ."The most readily expressed reason for rejecting Barbie was that she was babyish, and girls saw her as representing their younger childhood out of which they felt they had now grown."

Regarding more serious matters, no doubt people expect me to comment on the avalanche of recent news. I think others are saying all that can be said, but Rep. John Conyers and the House Judiciary minority staff, who report to him, are doing the work the congressional majority ought to be doing, that is defending the constitution of the United States against all enemies, foreign and, in this case, domestic.

Mr. Conyers asked staff, by year end 2005, to review the available information concerning possible misconduct by the Bush Administration in the run up to the Iraq War and post-invasion statements and actions, and to develop legal conclusions and make legislative and other recommendations to him.

In brief, we have found that there is substantial evidence the President, the Vice President and other high ranking members of the Bush Administration misled Congress and the American people regarding the decision to go to war with Iraq; misstated and manipulated intelligence information regarding the justification for such war; countenanced torture and cruel, inhuman and degrading treatment and other legal violations in Iraq; and permitted inappropriate retaliation against critics of their Administration.

There is a prima facie case that these actions by the President, Vice-President and other members of the Bush Administration violated a number of federal laws, including (1) Committing a Fraud against the United States; (2) Making False Statements to Congress; (3) The War Powers Resolution; (4) Misuse of Government Funds; (5) federal laws and international treaties prohibiting torture and cruel, inhuman, and degrading treatment; (6) federal laws concerning retaliating against witnesses and other individuals; and (7) federal laws and regulations concerning leaking and other misuse of intelligence.

The minority goes on to call for an impeachment investigation. Not going to happen, of course. Mr. Bush could do The Aristocrats act on national TV and Carl Cannon would extol his Lincolnesque vision.

I've been meaning to say something about Clostridium difficile for a while now, in part because I have personally had the extremely unpleasant experience of C. difficile disease, in connection with emergency abominable -- excuse me, abdominal -- surgery in 1991. Back then, C. difficile (hereinafter known as C) was known as a nosocomial infectious disease -- something hospitalized people get. The disease happened when otherwise debilitated people were given powerful antibiotics, which wiped out the normal symbiotic intestinal flora, allowing C to flourish. The symptoms, if you're lucky, are severe diarhhea. Worst case, it damages the colon permanently (or kills you).

Recently there has been a sudden, sharp rise in incidence in the U.S., from about 35 annual hospital discharges per 100,000 population in 2000, to more than 60 in 2003. Similar rises have been seen in Canada and the UK. For people 65 and older, the incidence is now more neaerly 350 per 100,000. (Per McDonald et al, 14th annual meeting of the Society for Healthcare Epidemiology of America, 2004.) Just as disturbing, the disease has shown up in the community, notably in Toronto earlier this year.

An analysis by Michael Warny of Acambis labs in Cambridge, Massachusetts finds that many cases are associated with a new strain that produces both kinds of toxin associated with C (most produce mostly one or the other). Now, Sandra Dial and colleagues from McGill University report in the new JAMA, based on data from the UK, that people taking proton pump inhibitors -- you know, that purple pill and its cousins which are constantly advertised on TV -- are at higher risk of getting C disease. Of course, widespread use of antibiotics may also be associated with the increasing incidence.

Here are some more dots to connect. Barry J. Marshall and J. Robin Warren won the Nobel Prize in medicine for discovering that the bacterium Helicobacter pylori causes stomach ulcers. Well, not exactly. H. pylori infection used to be nearly ubiquitous among humans, but only a minority got ulcers. So the cause of ulcers must be more complicated. However, it is true that if you eliminate H. pylori from the gut, ulcers heal.

However, it's not only people with ulcers who have had their H. pylori eliminated, it's most of us, because most of us, at one time or another, have taken courses of antibiotics for various reasons, and they happened to kill the H. pylori in the process. That's good news as far as the prevalence of ulcers is concerned, but there are indications now that H. pylori, when it wasn't acting as a necessary condition for ulcers, was suppressing gastric acid production and protecting us against Gastroesophageal Reflux Disease, in which stomach acid damages the esophagus. So that may account for the rise in prevalence of GERD, which caused lots of people to be prescribed proton pump inhibitors, which is now making them susceptible to C. difficile . . .

The fact is that each individual human is a complex ecosystem unto itself, which also interacts complexly with the organisms around it. When we intervene in this system, we are begging for unintended consequences. We need to be as conservative in our interventions. Proton pump inhibitors are heavily marketed, and lots of people take them who don't need them, people who don't have GERD but just plain old indigestion, who can benefit just as well from much cheaper conventional antacids. And of course, those of us who don't have ulcers would probably do well to hang on to our H. pylori, meaning not take antibiotics if we don't really need them, which is a good idea for many other reasons as well.

Monday, December 19, 2005

I do not believe that the people are going to put up with this crap any longer. A college student got a visit at his parents' home in Massachusetts from two federal agents because he checked out a copy of Mao's "little red book" from the library. The book is on a "watch list." As it happens, he was researching a term paper on Communism.

I hereby declare that I own a copy of that particular book. I also own a book entitled Mao Tse Tung on guerilla war. Come and get me.

Mary Robinson, the former UN High Commissioner for Human Rights, and UN official Paul Hunt, with support from such worthies as Jimmy Carter, Bill Clinton, and the ubiquitous Bono, have launched a campaign to have the world acknowledge health as a human right, under the banner of their organization Realizing Rights, The Ethical Globalization Initiative. (There's a petition there that you can sign if you are so inclined.)

Of course, this could be viewed as redundant and repetitive. In fact the Universal Declaration of Human Rights already does this, as do various other treaties that most nations have signed. Indeed, the the international covenant on economic, social, and cultural rights famously declares, "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being . . ." As we have discussed here before, this statement is a nice sentiment, but it is largely meaningless. Without going into the practical and philosophical complexities of trying to make sense of the covenant, Realizing Rights cuts the Gordian Knot by asking governments around the world to acknowledge a standard of basic needs, calling on goverments

To promote access to clean water, health care, adequate nutrition and sanitation without discrimination;To invest in strong health systems;To make sure that health care decisions are made accountably and with public participation;To support low-income countries in their efforts to bring decent health to their peoples

Unfortunately, the campaign is not redundant because these basic rights are not honored by the world's governments. The single biggest offender is the United States. The Bush administration has refused calls by the leaders of the other developed nations to contribute .7% of GDP to development aid; refuses to provide public health assistance without guarantees that recipients won't promote family planning and use of condoms; zealously defends patent rights that keep essential drugs expensive; refuses to eliminate agricultural subsidies that dump massive quantities of cheap grain on world markets and so destroy developing countries' agricultural sectors; and oh yes, does not provide health care to tens of millions of its own people, while yapping about something called a "culture of life." So I guess we need to sign the petition.

Sunday, December 18, 2005

So it turns out that the claim by Korean scientist Hwang Woo-suk to have created human embryonic stem cells by cloning adult somatic cells may be fraudulent. Whenever such spectacular allegations of scientific fraud surface, some people will raise questions about the integrity of the scientific enterprise, or even the validity of the entire structure of scientific belief.

On the contrary, this incident cogently demonstrates the power of science. Either it is possible to create human embryonic stem cells by the methods Hwang claimed to have used, or it is not. If it is not, other scientists will discover that they cannot reproduce Hwang's results, and that will be the end of it, regardless of the denoument of this case. If it can be done, it will be done, even if Hwang in fact did not do it.

Some people think that we social scientists have a different view of truth than so-called "hard scientists" like biologists or physicists. We do not. (I acknowledge some embarassing departures from the epistemological consensus by some people who called themselves social scientists, particularly during the 1980s and 90s. Fortunately, the era of transgressive hermeneutics appears to be receding in the rear view window.) We are however perhaps somewhat more alert than other kinds of scientists to the existence of various kinds of truth.

The behavior of human cells when subjected to various manipulations, like the composition and motions of the heavenly bodies or the quantum states of the beryllium atom, is out there to be discovered. Although some people may have opinions about these matters that differ from scientific findings, it would be senseless to think of these truths as socially constructed or culturally dependent. (Of course, their importance or meaning to people might be.)

However, questions like the prevalence of depressive disorder or how best to treat it, or the nature and extent of racial disparities in health care, are quite different. Depressive disorder, like most of the psychiatric diagnoses, is defined as whether or not a person reports a certain percentage of a list of subjective feelings and sensations, at levels of intensity which are generally defined qualitatively. While people have various theories about specific, measurable biological states that might correlate with getting a diagnosis of depression (such as a "deficiency" of serotonin in certain parts of the brain) there is no convincing evidence for any of these. The disease of depression, like the personality disorders, is indeed socially constructed, by a consensus of psychiatrists assigned quite frankly to the task of constructing it. The definition of whether depressive disorder responds to various treatments is likewise socially constructed, as whether people's responses to a list of questions change by a certain arbitrary amount. One can easily and quite defensibly decide to use different criteria for diagnosing depression or the remittance of depression, whereupon the prevalence of the disorder and the effectiveness of treatments will also change. (Note that this is not true of all diseases.) Indeed, it is possible to make the disease of depression go away altogether simply by denying the ontological status of the bundle of observations that constitute it.

Then there is the realm of ethics -- what ought to be, including how people ought to behave, and what we ought to desire. Truths of the first kind -- such as our origin in biological evolution, or how people of various cultures and personal characteristics respond to ethical puzzles -- may inform ethical discussion but cannot finally settle ethical questions. Truths of the second kind -- what cases belong to certain categories -- also are obviously very important in ethical discussion but there is often no good way of settling them.

Scientists sometimes claim to have settled questions based on their findings of the first kind, when in fact those findings rest on truths of the second kind, and can be challenged on that basis; or else their prescriptions depend on ethical choices which may be made differently. Critical thinking depends on being able to keep these kinds of truths separate, and to process each of them in the appropriate way. So it is possible to criticize the scientific enterprise, to make claims about science having biases, or leading society astray in some way, without denying the epistemological claims of science.

When I talk about democratizing science, I don't mean deciding on scientific truth by taking a vote, or anything remotely like that. I hope we can have more discussion here about what I do mean, and what the idea of democratizing science means to some of you who read this.

We're talking about drug companies writing articles for medical journals, and paying academic specialists to pretend to be the authors. We aren't talking here about research reports -- the issues with drug companies running clinical trials and, in one way or another, managing the study design, analysis and reporting to appear favorable to their products have gotten plenty of attention here already. In those cases, the academic authors generally did really work on the studies, but the concern is that their conclusions may be influenced (or worse) by the funding source. The kinds of articles we're talking about here are clinical reviews, what you might call "how to" articles for physicians that give recommendations for use of particular drugs. (Matthews somewhat conflates these two situations, I am drawing the distinction.)

When they are caught out, the putative authors of these ghostwritten sales pitches generally claim that they reviewed the pieces and approved of their contents. The drug companies claim that these eminent professors are too busy to write a whole lot and maybe aren't the world's greatest writers anyway, so the practice helps humanity get the benefit of more of their mighty brainpower.

I say pish tosh and poppycock. If a student hands in a paper under his or her own name, that she or he did not write, we expel that student. It's called academic dishonesty. Most scientific papers are team written but the names of all the people who made substantive contributions are required by journal policy to be disclosed and appropriate authorship credit given. I'd feel a whole lot different about a clincal review knowing it was written by an employee of a drug company than I would if I thought it was just written by Dr. Bigname Knozall. And by the way, publication is the main currency of academia, determining promotions and tenure.

If students are expelled for doing what Dr. Knozall has done, Dr. Knozall should be fired. And oh yeah -- the journal should retract the article, and sue him for fraud.

Friday, December 16, 2005

As long as we're doing initials . . . PLoS stands for Public Library of Science. At the blogger panel in Philadelphia, I mentioned that I'm often frustrated because I can't link to subscriber-only journals. Audience members had a good deal to say about this subject.

The way it works now, new scientific knowledge is generated (for the most part) in universities, which are then required to give it away free to scientific publishers, who sell it back to them at exorbitant prices that the general public, and even most public libraries, can't afford. (Subscriptions to scientific journals cost hundreds of dollars a year.) As a matter of fact, even university libraries in less wealthy countries can't afford to subscribe to many journals, although some publishers have started to offer discounts to subscribers in poor countries.

To be sure, few non-specialists are interested in reading the sorts of highly technical reports on the latest, typically very narrow findings in physics, biology, or biomedicine that make up the bulk of scientific publication. However, journals of medicine and public health have a great deal of material on public health and health policy that would indeed be of interest, and accessible to, literate lay people, if they could get their hands on them. (One thing you can do is subscribe to Scientific American, which will keep you up to date on the broad range of scientific endeavor.)

A fairly new project, the Public Library of Science, makes academic science free to all by posting its journals on the world wide web. It's financed by the authors, but its still peer-reviewed -- you don't get published just because you pay. PLoS Medicine is the one that's relevant here. For example, Here is an interesting article by Lacasse and Leo about SSRIs. Contrary to the popular mythology, which is pushed heavily by the drug companies in their advertising as fact, there is no good evidence that depression, or any of the other newly invented diseases for which SSRIs are prescribed, is caused by a "deficiency" of serotonin, or any other specific "chemical imbalance" in the brain. Why anti-depressants work, to the extent they work at all (which is not much, at best) is completely unknown.

A librarian in the audience also suggested that many public libraries subscribe to services that make a range of journals available on-line, so you might want to try your public library if you're interested in that. But I want to make my sources readily available here, so I'll be turning to PLoS Medicine again in the future, I'm sure.

Thursday, December 15, 2005

That's not an acronym because you can't pronounce it (KaBopper?), it's the abbreviation for Community Based Participatory Research. This is an increasingly popular concept intended to address the power imbalances and exploitation that many people perceive in the way public health research is typically done.

Conventionally, a learned professor ensonced among ivy-covered walls deems some environmental hazard or social pathology worthy of study, and wangles a major chunk of change out of the taxpayers on that basis. The money pays a portion of the learned one's upper middle class salary, plus chump change for a bunch of graduate students who go out and collect a lot of information about the endangered or pathologized people, which they all then process into an article about odds ratios or beta coefficients which is published in a journal that costs $300 a year. The publication then becomes evidence in the learned professor's case for tenure or promotion, and for further grants.

CBPR principles include involving "the community" in defining the problem and the methods for studying it, benefiting in some way materially from the major chunk of change, and interpreting the results. "The community" also gets to actually learn what the results are, and if we're really cooking with gas, converting the new knowledge into some sort of action to solve problems. Of course there are multiple problems here, not the least of which is how to define, and then to represent, "the community," since the best you can actually hope for is some small group of actual real people who are intended to stand for the whole. And of course, it is extremely challenging to eliminate, or even substantially reduce, the power imbalances that will still exist within whatever participatory structure you create.

CBPR advocates generally recognize the problems and wrestle with them honorably. Nevertheless, in what I saw of the representation of CBPR at the APHA meeting, the medium is the message. We had learned professors standing on podiums addressing an audience three feet below, describing how they were empowering a lot of people who weren't there. Sometimes we had, speaking for the community side, a director of non-profit organization whose list of degrees might stop short of bestowing the magic word "doctor" -- somebody with an MSW or a Master of Public Administration, say. One presentation I heard, entitled "Being the community in community based research," described the speaker's travails confronting the power, insularity and self-absorption of academic scientists and their institutions. Fair enough, but the speaker is the director of an independent but university-based institute with millions of dollars in grant funding, who has been an executive for more than twenty years.

One place the community definitely wasn't was at the APHA meeting. Of course, the $300 registration fee and the $170/night downtown hotel rates might contribute to that.

Tuesday, December 13, 2005

You may not hear from me again till Friday - I'll try to get something up Thursday but it will be tough.

The panel on bloggers was great, a lot of fun. We had a good audience -- quite a few of the people have their own blogs, in fact, but what is most amazing is that some of them actually read this one. As I said, I was among people with truly influential sites, but the session needed the perspective of a regular person, I think.

A lot of discussion was about where this technology is going. There are many ways to use it that we haven't tried yet, blogs as well as wikis, and a lot that could be done to bring order to the public health blogosphere, help people find their way around, develop cooperative projects, and use the technology to coordinate the development of ideas, organizing, activism, discourse -- I hope we'll have the chance here to try some new things, and I'm even negotiating that with a couple of people.

The conference has given me considerable material, so I'll be writing about it in the days ahead. Had a long day though, have to drive back to Boston tomorrow and teach a class tomorrow night. So, expect me when you see me.

Yesterday I briefly mentioned a panel on food policy. The official title was "The Obesity Epidemic: Getting Beyond Individual Choices." The presenters discussed subjects we've paid a lot of attention to here. Americans aren't getting fat because we are lazy and gluttonous by nature. It's because greedy people are doing it to us.

Sarah Samuels talked about the "food environment" in the schools. The lunches prepared by those cafeteria ladies we all remember -- the sloppy joes and mystery meat -- are still happening, but schools today are full of vending machines and snack carts and even actual fast food outlets, all there because of contracts with the schools that they now depend on for financing that the citizens don't care to provide out of tax money. And what are these commercial enterprises selling? You know the answer. Sugar, fat, starch -- empty calories.

There is no hope for national school nutrition standards right now (viz. our earlier discussion about Congressman Boehnert's heroic crusade to save the junk food purveyors from Communistic tyrrany, violating their God-given right to poison our kids) but California recently passed standards, and local districts can as well. This is something citizens can take on at the local level. Get off your expanding behind, get down to the local school board, and make them get the junk food out of your schools.

Susan Roberts explained why we are eating so much sugar. It's because the U.S. government guarantees a high price to corn farmers, and the more they grow, the bigger the subsdies they collect. As a result, they keep growing more and more corn -- far more than we need. Some of it gets dumped on world markets at low prices, destroying the livelihoods of farmers in poor countries, and a lot of it gets turned into high fructose corn syrup, which becomes surgary soft drinks. The big food processors love to sell this stuff because it's very cheap to make, and they can sell it at a huge profit. So they market it aggressively, among other ways, by placing vending machines in schools. Today, according to Dr. Roberts, Americans consume the equivalent of 557 12-oz cans of soda per person, every year -- that's every man, woman and child, including babies. Teenage boys drink, on average, 913 cans a year. That's poison. It's killing us.

Why not subsidize spinach farmers, she asks? The subsidies obviously aren't going to preserve family farms, they're going to huge agribusinesses. We need an agricultural policy that rewards growing diverse, nutritious crops sold in short supply chains, mostly to local markets. That takes out the huge commercial interests that want to sell us processed foods made from the cheapest possible ingredients that can be mass marketed using cartoon characters. Then there are environmental issues, the consequences for social organization of the countryside, and the benefits for people in distant lands who are desperately poor. This just might be one of the most important issues we face.

According to the Philadelphia Inquirer, the guy who was arrested at the protest wasn't drinking iced tea, he was drinking lemonade. I'll go with the Inky's version since they had more time to interview witnesses than I did. And they say bloggers have no journalistic ethics.

The Inky also says that the guy who tried to intercede on the criminal lemonade drinker's behalf was his brother, so presumably it was his 3 year old nephew who the cops almost killed in their zeal to protect us from dangerous consumers of lemonade. The lemonade terrorist was charged with assaulting a police officer. However, the reality-based version of this incident is that the police assaulted him.

In a democracy, the police do not arbitrarily assault and arrest peaceful citizens who are expressing dissenting opinions. Is Philadelphia part of a democracy? Just asking.

Monday, December 12, 2005

First of all, for reasons that are too complicated to explain here, I've lost access to my e-mail until Wednesday at the earliest. If I don't have time to catch up when I get back to Boston, but before my Wednesday night class, I won't be able to use e-mail till Thursday. Sorry.

Numero dos. Get Firefox. Forget about Explorer.

3. If anybody who happens to be reading this is at APHA, the session on blogging is at 4:30 in the Convention Center, Room 103C. It turns out you can't stick up flyers everywhere at this one as is usually possible, so it's a little hard to publicize.

D. I'll be blogging about the meeting later tonight, I hope, and tomorrow morning, but might not be able to get much up about events tomorrow until Thursday. It's been great, interesting, worthwhile. But it's only a meeting of people who already mostly agree with each other about the stuff that matters the most. That's the frustrating part.

It's only 1:00 pm, and I've already had a long day. This morning I heard a panel convened by former APHA president Barry Levy on social justice and the Katrina disaster, then I went to a panel on U.S. food and nutrition policy. The room capacity was 79 and here we were, the American Public Health Association, violating fire safety policy by packing about 150 people in there. So now you know what's hot in public health these days. I'll have plenty to say about it, but first I have a more pressing issue.

A man who fraudulently pretends to be president of the United States just got done speaking at the World Affairs Council a few blocks away from the Convention Center. You already know where I was -- across the street with the protesters. The police tried to pen us in to a tiny free speech zone with barricades, but once the free speech zone was full, people kept showing up and since they were standing on a public sidewalk, they ended up staying there. Broad St. was closed to traffic, but the cops wouldn't let anybody stand in the street, so it was like the subway at rush hour. Police in plain clothes, with no badges showing but wearing police armbands, lined the sidewalk staring grimly at the protesters. This crowd was not professional protesters. There was not a Workers World or ISO flyer in sight. These were just plain folks, all ages, all colors. A lot of union members in fact -- communication workers, SEIU.

A man a few feet away from me was drinking iced tea from a bottle when a police man waded into the crowd and started to arrest him. Seriously. Evidently there was some sort of rule that protesters weren't allowed to have bottles, but I assume this guy didn't know about it. I certainly didn't. Another man, whose three year old son was riding on his shoulders, tried to intercede, when the cop pushed him roughly away and nearly knocked the child to the ground. People surged foward to save the child, whereupon police started wading into the crowd with their batons raised. The scene turned ugly, police shoving people aside and throwing punches. They finally dragged the guy with the iced tea away and into a van. His mother started pleading with them, but they wouldn't let her near him. The guy is African American, as was the guy with the little kid. (So were at least half the cops, by the way.) I introduced his mother to an eyewitness who is a Philly resident and will still be around, and he promised to help her. I'll read the Inquirer tomorrow and if they file any charges in this case, I'll let you know.

This is pretty typical of protests these days. The police show up looking for trouble, and they make sure they get what they want. There wouldn't have been any trouble at all if there hadn't been any police on the scene. As far as I'm concerned, they should have turned around and faced the Bellevue along with the crowd. They're honest American folks too (or at least we hope so), and that means we're on the same side. Or at least we ought to be.

Sunday, December 11, 2005

This computer I borrowed from my employer is so jammed up with spyware, adware, evilware, bacteriaware, and parasiteware that I expect everyone from the CIA to Merck is logging my keystrokes, but what the heck, I got nothin' to hide.

I went to college in the Philadelphia suburbs so back in the day I drove from Connecticut to Philadelphia a few times a year. Doing it again a bit later -- well, okay, it's been more than 20 years -- not much has changed. The Bronx from the Cross Bronx Expressway looks exactly the same - the el is exactly as rusty as it was in 1980, it seems as though the same tenement buildings are still abandoned and the ones that aren't are still the same boxes whose only architectural feature is graffiti.

North Jersey seen from the turnpike is the most aesthetically repulsive region in the United States, in sight, sound and smell. It's our national sacrifice area, I suppose -- if we simply must have petrochemicals and dispose of our garbage, we need it. Philly has tried hard since I took it to the streets here as an oranizer. There are quite a few new hypermodern office towers, they've spruced up the Reading Terminal and they've even tried to give the subways a facelift. During the Lebanese civil war, the warlord Walid Jumblatt visited Philadelphia (for some reason) and he refused to go down into the subway. "Oh no," said this man who have braved a dozen assassination attempts, "I would never go down there." Well, they have new cars now that don't catch fire all the time, so that's progress.

Still, Philly seems worn out, like it's been fighting the inevitability of decline with a facelift and a tummy tuck, but it's only a holding action against time and gravity. We'll see. Maybe the city will ultimately manage to adjust to a smaller population and a peripheral place among the nation's big cities, but right now there are still a lot of vacant lots and empty storefronts. The new convention center and all the other amenities they've installed to try to bring the city center back are islands among porn shops, blocks of decrepit lofts and low rent offices, and just plain nothing but a bunch of junk.

It's just about the exact opposite of Atlanta, where the countryside is being devoured by metastasizing malls, condo developments, office towers, restaurant chains -- absolutely nothing is old. I'm not sure why so much of the nation's life force seems to be heading south, but at least here in the east, that's what's happening.

I got here too late for Sen. Kerry's keynote address, just wandered around the exhibition hall. The biggest, most spectacular display, believe it or not, belongs ot Lockheed-Martin. After a long, honorable corporate history of blowing people up, they have gotten into the consulting business and they do a lot of public health related work for the feds. Really. Coming in second, not surprisingly, is Pfizer. Merck is laying low -- only their vaccine division has a booth. But mostly it's the schools of public health, federal agencies, some non-profits, and small businesses. This isn't your usual convention. It's extraordinarily ethnically diverse -- it really does look like America, only more so. The people do a lot of different kinds of jobs and make very different incomes. But we have a common purpose. That's good to know.

Saturday, December 10, 2005

As I may or may not have mentioned, I'm off to Philadelphia for the American Public Health Association meeting. This was going to be my first opportunity to visit New Orleans, where the APHA meeting was scheduled for November, but that sort of didn't work out. But who would pass up a chance to visit Philly in December?

I used to go to APHA every year, and I'd always submit two or three abstracts and give a couple of presentations. I stopped going for a while because, frankly, it's just too big and too much for its own good. There are hundreds of sessions, thousands of presenters, most of the panels are cobbled together out of three or four largely unrelated papers and it's impossible to figure out which ones you really want to go to. I always meet two dozen people who I exchange cards with and then never hear from again. There have been a couple of exceptions -- one year I had the opportunity to meet Mysterious Anonymous Reader, who sometimes contributes items to this blog, and I have run into one or more of the Reveres on occasion, as well as other friends.

One thing is for sure about APHA meetings though -- public health is a unique field of endeavor. It's an academic content area, not a specialty, so we have mathematicians, biologists, physicians, psychologists, sociologists, economists (yes, we let them in for some reason), lawyers, managers -- you name the discipline, we got it. We also have practitioners, the majority of them public employees, and also people who work for community based organizations. I have a foot in all three worlds -- academic, public, and community -- which makes me a bizarre trilaterally symetric extraterrestrial. One thing we all have in common is that we're talking about public health, which means we all believe fervently in the public sphere and the public good. That does mean that inevitably, certain currently popular political ideologies don't get a lot of support there.

This year, in addition to doing a poster session (yes, it's humiliating), I'm going to be on a panel of public health bloggers -- and I'll definitely be associating with my betters. The organizer of the panel is Jordan Barab of Confined Space, and a representative of Effect Measure will also be there. I think my role is to explain how any loser can start a blog.

So I'll be posting from the meeting and I'll let y'all know all the hot news from the realm. For a change, I'm looking forward to it this year, and I hope we'll have some interesting things to talk about.

Friday, December 09, 2005

Merck claimed that it did not know that Vioxx increased the risk of heart attack and stroke until a study last year, after which it withdrew the drug from the market. The company and its hired researchers, notably Dr. Alise Reicin, who has testified on behalf of the company at the Vioxx trials, claim that an earlier study published in The New England Journal of Medicine in 2000 showing an increased risk of heart attack in subjects taking Vioxx, as opposed to Aleve (naproxen), demonstrated a protective effect of Aleve, not a harmful effect of Vioxx.

It turns out, according to the editors of NEJM, that the 2000 study could only be interpreted in that way because it was fraudulent. They have posted an editorial on-line, available to non-subscribers (PDF). Specifically, the authors of this study knew of three additional heart attacks in the Vioxx groups which they did not report. This raised the relative risk for Vioxx users from 4 to 5. They also deleted information from the manuscript about strokes and other vascular problems.

The company then went on to continue to market the drug aggressively for four years.

As our readers are probably tired of hearing, our enormous investment in so-called "health care" in the U.S. -- now 16% of the economy and growing -- isn't paying off. One reason is that our non-system, a patchwork of perverse market incentives and regulated sectors designed more to satisfy political constraints than to keep the population healthy, ends up allocating disproportionate resources to specialty care and high technology interventions for already sick people, than to primary care intended to catch problems early and keep people healthy.

Robert L. Phillips discusses the present and future of primary care in the U.S. in, where else, the British Medical Journal. (Sometimes you need your friends to tell you what you can't see about yourself, it seems.) Primary care docs in the U.S. -- internists, pediatricians, and family medicine practitioners (familiatricians?) -- are paid less than half as much as radiologists. They have far too little time to spend with patients -- from their own point of view, as well as from the patients' point of view. Relatively lucrative diagnostic and surgical procedures, as well as care for their patients when they are hospitalized, are increasingly being taken away from them and given to various categories of specialists. Patients' lack of continuity of insurance coverage means that primary care physicians often have only short-term or episodic relationships with patients.

Given the patchwork of financing for health care in the U.S., the scope for government policy to fix this problem is somewhat limited, but certainly Medicare can do a lot. Medicare can increase reimbursement rates for primary care, and assure that more primary care preventive services are reimbursable. State Medicaid programs can do the same. In addition, although Phillips does not say it, we need to find ways to redirect the investments being made in medical services and research in the U.S. Capital is flowing to lucrative, high technology equipment, tertiary care hospitals, and research into expensive treatments for preventable diseases, such as heart disease and Type 2 diabetes. Public policy can direct more research dollars toward such subjects as effective physician-patient communication in primary care (if I do say so myself), practice improvement techniques to enhance coordination of care (which primary care physicians were once expected to do), and enable more procedures to be performed in primary care settings, presumably at lower cost and with better integration into patients' overall treatment.

Compensation for the primary care specialties has to be made more comparable to that of other specialties, so that more young physicians will go into the field. Right now, starting primary care physicians will struggle to pay their educational debts, which are typically more than $100,000. And, if doctors are better reimbursed for each episode of patient contact, they can spend more time with patients. A basic problem is that talking and listening are the least well compensated procedures. But they are the most important ones.

Thursday, December 08, 2005

The percentage of mothers who did not begin to receive prenatal care until the third trimester, or who received no prenatal care at all, rose from 2003 to 2004, from 3.56% to 3.59%. While this is a small increase, it is based on data from 99.1% of live births, not a sample. In other words, the phenomenon is real, there is no confidence interval for it. This number had been falling steadily since 1990.

Of more import, the pre-term birth rate rose by 2%, continuing an upward trend. Even worse, the low birthweight rate rose from 7.9% to 8.1%, also continuing a trend. Low birthweight is the principal factor associated with infant mortality and morbidity. A larger number of multiple births -- probably due largely to fertility treatments -- accounts for only part of these trends.

These are among the most important standard measures of population health, widely used for international comparisons. So there you have it -- we're still spending more and more on health care than any other country, and we're still getting less and less for it in the overall health of our population. Why? That's easy. We have the most inequality of any of the wealthy countries. The rich get richer, and the poor get sick and dead babies. The mistake these babies are making, from the standpoint of getting any political support, is that they are being born. Once they are born, they no longer have a right to life.

David C. Reardon is an anti-abortion activist who has adopted a unique strategy -- to try to convince the world that abortions are harmful to the women who have them. His organization, the Elliot Institute, has a web site called AfterAbortion, which archives numerous "scientific studies" purportedly showing that abortions are traumatic and psychologically damaging, etc.

Reardon managed to get a study published in the British Medical Journal in 2002, finding that women who terminate an unwanted first pregnancy are at higher risk for subsequent clinical depression than women who carry the pregnancy to term. Now Sarah Schmiege and Nancy Felipe Russo have taken another look at the same data and found that no such thing is true after all. On the contrary, women who chose to end unwanted first pregnancies end up with higher levels of education and smaller family size (obviously) and are probably at lower long-term risk for depression as a result.

Why the difference? Reardon and his collaborator manipulated the data in various ways in order to produce their result. For example, they excluded women in the group who delivered who then had abortions later on. Since people with multiple unwanted pregnancies are probably more likely to experience depression, this had the effect of reducing the apparent incidence of depression in the women who delivered. (Got that? It's a little tricky. Depression in women who have an unwanted baby when they are young is likely a risk factor for having subsequent unwanted pregnancies. By eliminating these women from his sample, Reardon rigged the outcome.)

Scientific research, unlike theology, is not a method for demonstrating a preconceived conclusion. It is based on the principle that the truth exists independent of our preferences about what it ought to be, and awaits discovery, not invention. For the modern conservative movement in this country, that definition of science does not apply. Activities intended to promote some convenient belief -- that environmental tobacco smoke is harmless, that burning fossil fuels does not contribute to global warming, that abortion causes abortion or breast cancer -- are disguised as scientific research. This pseudo-science is typically sponsored by entities that will benefit from a particular outcome -- the oil or tobacco industries, or religiously motivated anti-abortion activists. Earlier we discussed the bogus anti-gay research of Dr. Paul Cameron. Then of course there is the Discovery Institute, which promotes so-called "Intelligent Design."

Unfortunately, very few science journalists have either the skill or the motivation to sort this out for us. Real science and tendentious pseudo-science are presented side-by-side, with equal credibility, on the TV and in the newspapers. They call it journalistic "balance." With the federal government now engaged in promoting pseudo-science, real scientists need to be much more engaged with the public.

Wednesday, December 07, 2005

Robert Hurley, Hoangmai Pham, and Gary Claxton, in Health Affairs (and this one is free to all, no subscription required), report on new information from the Community Tracking Study, which is a largely qualitative ongoing study of health care markets in metropolitan areas selected to be representative of the U.S.

There is too much detail here to really do justice to it in a summary, but the main idea is that there has been a strong trend toward growing inequality in access to high quality health care. Investments continue to be made in new facilities which are not only state-of-the-art, and have the latest and greatest equipment, but also offer lavish amenities to consumers. There has been growth in the development of free standing specialty care centers, where highly paid medical specialists can ply their trades without the burdens of working in a general hospital where they have to do things like cover the emergency department and take care of people without the best insurance. Meanwhile, primary care providers continue to lose ground in compensation. People with private, employer-provided insurance, and Medicare beneficiaries, have access to this high quality, high priced care, and they continue to benefit from the latest in medical technology.

At the same time, states have cut back severely on Medicaid benefits, both reducing payment to providers and eliminating coverage for some services. As a result, specialists don't want to take care of Medicaid patients. They are consigned to community health centers and other providers, which don't have the amenities, or the great equipment, and are overburdened. Medicaid beneficiaries often have difficulty getting specialty care at all. And then, of course, there is the sharp rise in the number of adults with no health care insurance at all, who get only urgent care when they are seriously sick or injured.

The disparities in access to high quality care are exacerbated by the tendency for investment to flow to affluent areas. Hospitals serving poorer communities can't raise the capital to upgrade their facilities and equipment, so poor people are harmed by geographic disparities as well as the kind of insurance they have.

Because emergency departments are required by law to take all comers, they are a potential portal to care for people without insurance, or to higher quality or specialty care for Medicaid beneficiaries. Consequently, other providers try to dump patients on emergency departments. However, the EDs are having increasing difficulty in finding specialists who will be on call for them, and follow-up care for people who come in through EDs is even harder to find.

The people who fare the worst, as our readers know well, are the chronically mentally ill.

In my view, we are moving beyond a class structure in the United States to a caste system, in which the boundaries between social strata are almost impossible to cross. Once you lose insurance, and become sick (in whichever order), you will never be able to recover, because you will not get health care or rehabilitative services, therefore you will not be able to work, and you will never again have insurance, unless you are lucky enough to make it to age 65. That's what the culture of life will do for you.

Tuesday, December 06, 2005

The Institute of Medicine today released it's breathlessly anticipated report on marketing of food to children. The eminent scientists have discovered (get ready for it) that, according to Senior Scholar J. Michael McGinnis, "The foods advertised are predominantly high in calories and low in nutrition -- the sort of diet that puts children's long-term health at risk."

Now that they have made this major scientific discovery, what does the august Institute recommend? That the food and beverage industries should promote healthier foods, and that the media and entertainment industries should campaign for healthier diets.

Now see folks, I know you are really brilliant doctors and everything, but it's like this. The food and beverage, media and entertainment industries, do what they do for the following reason:

To make money.

Sugary junk food is cheap, very cheap to make -- and it's cheapness, by the way, is enhanced by agricultural subsidies that pay farmers to overproduce sugar and corn. It's very easy to get kids to eat it, and to eat a lot of it. Sponge Bob and his friends advertise it because they are paid to do so. TV networks run the ads because the food companies pay them. The food companies pay these companies to advertise their junk food because that's how they figure they can make the most money.

About the moral exhortations of the Institute of Medicine they give not a jot nor a tittle.

Thomas Frieden and colleagues from the New York City Dept. of Health and Hygeine, in the Dec. 1 NEJM, discuss ways in which our approaches to the HIV epidemic differ from our responses to other transmissible diseases. To some extent, I think, they exaggerate these differences, but it is worth having this discussion.

In the case of most reportable diseases -- and there are a lot of them, from Amoebiasis to Yersiniosis (plague), including embarassing ones like syphilis and gonorrhea -- laboratory directors and health care providers are required to report to the public health authorities information including the name, address and telephone number of the infected person. (And note -- this is an exception to the HIPAA privacy regulations. These reports are handled confidentially, but they do go to state and local authorities.) In the case of HIV, most jurisdictions do not have name-based reporting, although some states have introduced it. Here is one state's set of reportable diseases and reporting forms.

Also, for many common conditions for which inexpensive screening tests are available, people are routinely screened in doctor's offices. Not so HIV, for which in most cases an elaborate counseling regimen is required to go with testing. Then there is partner notification -- if you are diagnosed with an STD, the local public health authorities will ask you for information about your sexual partners. A person called a disease intervention specialist will then contact them, and inform them that they may have been exposed to what we used to call a "social disease," and offer them testing and treatment. In the case of HIV, that happens inconsistently, depending on the jurisdiction.

There is also less systematic monitoring of whether people with HIV receive treatment than in the case of some other diseases of special concern; a more patchwork and inconsistent system of case management; and less systematic monitoring of the development of treatment resistant strains of the virus.

These differences principally arise from the highly stigmatized nature of HIV infection, particularly early in the epidemic, when there was also no effective treatment available. There were entirely legitimate concerns that anything less than absolute confidentiality would discourage people from getting tested; while at the same time, the direct benefit to the individual of knowing his or her HIV status was questionable. Today, although there is no cure for HIV, there are treatments that can be quite effective in most cases at slowing progression of the disease and giving people many years of productive life. At the same time, the stigma associated with HIV is much less, at least in large parts of the country. These developments suggest that the public health benefits of name based reporting, partner notification, and monitoring of treatment in individual cases as well as at a population level may now outweigh some of the earlier privacy concerns.

I have reservations about this argument. However much we may like to believe that we are now more enlightened, as a society, about HIV, for many people at risk for the disease, stigma is still a huge worry. I know many people who have not been able to disclose their HIV status to close family members. People are shunned and abused in prison because they are HIV positive, and may lose employment or suffer other harms. Many addicts and prostitutes do not visit doctors offices; some people who do see a doctor regularly might not want their doctor to know about their HIV risk behaviors. That's not desirable, but it's reality. Community based testing programs are still necessary, and being able to at least offer confidential testing is still desirable in many cases. With confidential testing, must come counseling, for various reasons which don't fit in a blog posting.

I do support universal availability of voluntary partner notification; case managment, without the overlap, duplication and gaps that currently exist (maybe more on this later); and follow-up monitoring of entry into treatment. The latter can be accomplished within a confidential reporting system by making the testing agency responsible for it, although it would eliminate the option of anonymous testing, which still exists in some jurisdictions. (Confidential testing means no reporting of identifying information to the authorities; anonymous testing means the testers don't even have identifying information.) But these issues require discussion by all the people affected -- people with HIV, people at risk for HIV, counseling and testing providers, HIV service organizations, public health authorities, citizens -- not just an essay by authorities in a medical journal.

Then there are the questions of condom promotion and needle exchange, where the fracture is along entirely different lines. More on that later also.

Monday, December 05, 2005

Remember when there used to be people called "moderate Republicans"? You know, those scions of prominent families who learned all about fair play in prep school and whose mothers taught them to be charitable toward the servants? They were certainly friendly to big business -- after all they had to be able to show their faces at the country club -- but they liked national parks and clean rivers; didn't mind taking a little bit off the top of the dividend stream for taxes; liked spending aircraft carriers full of thousand dollar bills on ships, planes and tanks but were fairly averse to actually using them; hated budget deficits, because they wanted their bonds to hold their value; and were willing to throw a few dimes out the window of the limo to the wretched refuse on the sidewalk.

It seems they may be back. From The Oregonian (brief, painless registration required):

Sen. Gordon Smith, R-Ore., said Wednesday that he will vote against a massive budget bill being considered in Congress if it includes cuts in the Medicaid and food stamp programs that he and a handful of other Republican senators strongly oppose.

Smith's unequivocal statement could be critical in shaping the final version of the 2006 Budget Reconciliation Act. The continued opposition by him and the other GOP senators would all but doom any bill containing the Medicaid and food stamp cuts in the Senate. snipSmith added that he thinks the six Republican senators who have joined him in opposing the cuts "will hold with me."

Under growing pressure to reduce the federal budget deficit, House Republican leaders passed a version of the budget legislation that would slash about $50 billion over five years. The House bill included steep cuts in Medicaid -- the joint federal-state health insurance program for the poor -- and the food stamp program.

In the Senate, Smith was instrumental in crafting a measure that would cut the budget by about $36 billion over five years. It makes relatively mild cuts in Medicaid that would not directly affect beneficiaries and does not reduce food stamp spending.

That version of the budget bill passed the Senate by only five votes, meaning Smith and his six GOP allies could hold the balance of power in deciding the outcome of the budget battle.

snip

"The central strand in America's safety net is Medicaid, and it must not be weakened," he said. "Food stamps, like health care, ought to be a part of what America holds out to the disadvantaged in our society."

About 220,000 Oregon households receive food stamps. Under the House bill, an estimated 15,000 Oregon households would be cut off.

Several Medicaid and food stamp beneficiaries attended Wednesday's news conference and thanked Smith for his stand.

Ron Pollack, executive director of Families USA, a health care consumers' advocacy group based in Washington, D.C., said Smith played a "heroic role" in the Medicaid fight.

"Senator Smith," Pollack said, "has been the --and I underscore the word the -- most important leader in protecting Medicaid in the United States Congress."

Now, he still represents a vote for Republican control of the Senate, and I don't see him out there wanting to investigate the phony case for war, torture, war crimes, administration incompetence and corruption, or any of that other really nasty stuff that a Democratically controlled chamber would blow the lid off. He's all for the Bush tax cuts for the wealthy, of course, but he's also for stem cell research and he emphasizes nicer stuff like USAID over kicking butt with the army in his foreign policy rhetoric. And BTW, in good old Republican conservationist tradition, Smith opposes oil drilling in ANWR. So now you know we're non-partisan here, without fear or favor.

I've now had a chance to carefully read the original NEJM article by Patrice Severe et al on antiretroviral therapy in Haiti. As I said before, it isn't news that ARVs can be successfully administered in poor countries, but some people had remained skeptical about Haiti, which may present one of the most difficult environments.

But there is a bit of a -- puzzle? dilemma? oddity? Most Haitians live on less than a dollar a day. (That, believe it or not, is the World Bank's official international poverty line.) The program to treat HIV with ARVs, described in the article, costs about $1,600 per person per year. That includes providing food -- rice, beans and oil -- the most undernourished patients, and nutritional supplements to all of them. The participants also were treated for TB and other co-morbid conditions.

Now, think about this. Most Haitians are probably borderline malnourished, and a high percentage of them suffer from clinical malnutrition. But now they can get an adequate food supply -- if and only if they are HIV infected. Most Haitians seldom or never get to see a doctor, even though many of them carry tuberculosis and have other chronic diseases. But they can get comprehensive medical care -- if and only if they are HIV infected.

It is rather odd, and not entirely clear, why there is public demand, and government and philanthropic support, for taking care of people in impoverished countries who are infected with HIV, but no comparable demand for doing anything much about all of the other severe health problems faced by people in these countries. Under the present regime, it might actually make sense for some people to go out and deliberately acquire HIV infection in order to get access to medical care and nutritional benefits.

By the way, there are comparable situations right here in the U.S. -- housing, vocational, mental health and substance abuse treatment programs that are available only to people living with HIV. Some people actually claim falsely to be HIV infected in order to get access to these programs, and the programs have to require proof of HIV infection. But people without HIV are out of luck -- no mental health care for you, pal, you failed to practice unsafe sex or share needles.

Sunday, December 04, 2005

When I was 15 years old, a boarding school student, the United States, accompanied by troops of the puppet South Vietnamese government, invaded Cambodia. The result was a firestorm of protest. On May 4, 1970, national guard troops fired on unarmed demonstrators at Kent State University in Ohio, killing four. In response, striking students and faculty shut down hundreds of colleges and universities. My boarding school -- which happens to be the same school from which George W. Bush had received his high school diploma a few years earlier -- was also shut down. Shortly after that, I was kicked out of the band for wearing a black arm band in the Memorial Day Parade. Yup -- wearing a black armband at a ceremony to honor the dead was an unacceptable political statement. As I was collecting signatures on a petition to end the war in downtown Andover, a man said to me, "Do you want to be a Communist slave? Get wise to yourself!"

The war continued for three more years, but in the face of massive protests, Richard Nixon was forced to systematically withdraw U.S. troops, and in 1973, to sign a peace agreement which amounted to capitulation. Two years later, the U.S. withdrew completely from Vietnam and the country was reunified under the Communist Party. Of course, no harm to the U.S. or the world came from that. No dominoes fell, and neither that man in Andover nor I became Communist slaves. Today, the U.S. has normal relations with Vietnam, which supplies us with coffee and shrimp.

The movement against the Vietnam War began in the context of the Civil Rights movement, which became the Poor People's Movement; and the women's movement. All of these social movements engaged millions of Americans in activism. And that energy continued. I participated in marches on Washington against U.S. military involvement in Central America (citizen protest almost certainly prevented the Reagan Administration from invading), and nuclear power; I spent a year of 80 hours weeks working as a community organizer in Philadelphia, and we filled the streets and the City Council chambers with protests against the racist Rizzo administration. Once we shut down a City Council meeting with our chants while our friend and ally John Street, who is now the Mayor, filibustered on the council floor.

Even into the 80s, with Mobilization for Survival in Boston, I was part of an active, visible movement of citizens for all that good stuff -- peace and justice.

So what the hell has happened? Today, we have the worse presidential administration in the country's history, and a Congress completed controlled by an alliance of atavistic religious fanatics and rapacious capitalists. We are engaged in a war even more dangerous to the world and, if such a thing is possible, more pointless than the Vietnam War. The global environmental crisis, the hollowing out of the U.S. economy, growing inequality, national decline and planetary peril -- it really ought to be enough to have an uprising.

Sure, there are a few signs of life in the populace, some relatively modest antiwar demonstrations, lots of people like me bitching and moaning on blogs, some of which are widely read. But there is no mass movement, no political opposition. The pathological liar, war criminal president is now unpopular, but it doesn't matter very much. I'd be out there protesting, if there was anything to join. But there isn't. Why is that?